Evaluation of Chest Pain

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Evaluation of Chest Pain

• William Norcross, M.D.

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Evaluation of Chest Pain

• Dictum
• With any chief complaint or symptom complex,
  first rule-out (R/O) life threats.
• The stopping point in the R/O should be at the
  point of your conviction and personal
  satisfaction that the life threat does not exist.
  
• The R.O process may be very short and simple,
  e.g. a directed histroy, but if you're not
  convinced that the life threat is absent, pursue
  the R/O as far as necessary.

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Chest Pain is very common.

• gt 40 recognized entities in differential
  diagnosis
• Life threat (practical)
• Acute coronary syndromes (ACS)
• Aortic dissection
• Pulmonary embolus (PE)
• Pneumothorax
• Pneumonia
• Obscure
• Boerhaves Syndrome
• Usually are discovered in W/U of above.

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Life-Threat Ruled Out

• Other entities
• Musculoskeletal/serosal problems
• e.g. costochondritis, intercostal muscle
  spasms/strain, pericarditis, pleurisy
• Treat with NSAID, opiates, acetaminophen, local
  measures
• GI pathology
• Dyspepsia, GE reflux esophageal spasm
• Some bad abdominal pathology presents as chest
  pain
• e.g. perfodrated viscous, pancreatitis,
  cholecystitis
• Usually apparent by HP
• Treat with antacids, antispsmodics, etc.

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Approach to Non-Life Threats

• Less urgent
• Trial error approach
• Evaluation
• HP, ancillary tests (CRX, EKG, perhaps dimers
  and cardiac markers)

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Approach to Non-Life Threats

• Pneumonia, pneumothorax easy to diagnose
• Note the diagnostic modality for tension
  pneumothorax is an intracostal needle, not a CXR.
• ACS, PE, aortic dissection all easy to diagnose
  if you do the work-up
• Triggered by suspicions raised by initial
  evaluation and R/O life threat

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Bad things to miss

• High mortality out-of-hospital (if undiagnosed)

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Pulmonary Embolism

• Physical exam tachycardia, tachypnea, ?sats, R
  heart findings, leg findings
• Ancillary - EKG, CXR, nonspecific d-dimer is
  usually ? (sensitivity gt 85)
• Assign likelihood of PE (low, high, intermediate)
  based on clinical gestalt or grading scales (e.g.
  Wells Criteria)
• If low probability and d-dimer is ?, quit
  (probably)
• If intermediate or high, or if low with ?
  d-dimer, further study (V/Q, CT angio, perhaps
  dopplers)

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Aortic dissection

• History triggers sudden,radiation,
  ripping/tearing
• Risk factors HTN, Marfans, coarctation, aortic
  valve replacement, bicuspid aorta
• PE
• Severe pain, distress (usually), pulses, BP
  differential, AI murmur, neuro deficits
• All are insensitive markers, varied specificity
• Ancillary data
• CXR usually abn (90) wide mediastinum, abn
  aorta non-specific, 10 normal
• EKG may show ST segment elevation

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Acute Coronary Syndrome

• Most important due to commonality as well as
  lethality
• Top of differential, first inquiry
• ACS against the field of everything else

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ACS

• History Full history
• Only 4 things are truly predictive of ACS
• Presence of chest pain
• Chest pain as chief complaint
• Radiation to shoulder(s)
• History of previous MI
• Risk factors (traditional) are not predictive in
  ED setting

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ACS

• PE full physical
• Only 4 things predictive
• Hypotension
• Diaphoresis
• Rales
• S3
• Markers
• CKMB troponin sensitivity lt 50 at 6 hrs
• Neg markers with unstable angina and often
  initially neg with MI
• Neg first set mandates at lest on additional set

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ACS EKG

• Diagnostic of MI (1 mm elevation ST segments in
  anatomically contiguous leads) about 50 of the
  time.
• Non-diagnostic (usually non-specific ST/T waves)
  in around 50 MI.
• Normal 5 - 10 MI
• If ST ? as above there is 80 likelihood of AMI
• If new ST ?1 mm with inverted T in anatomically
  contiguouse leads, 20 chance of AMI, 20 -- 50
  change unstable angina (UA).
• If old ST changes as above and acute chest pain,
  5 chance AMI and 20 - 50 UA.

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Acute Coronary Syndrome

• If ACS is Ruled In (with EKG or markers) treat
  and admit.
• If not, then
• If strong suspicion, teat, admit, further R/O
• If convinced not ACS (or other potentially
  serious problem) -
• treat symptoms, outpatient manage
• If unsure -
• treat, admit, further R/O

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ACS

• Approached with clinical gestalt.
• More objective decision aids available (ACI -
  TIPI).
• Clinical sensitivity of either approach, gt 95.
• Not good enough the 5 (approximate) do badly.
• If in doubt, assume the worst, treat and admit
  for further evaluation.

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References

1. Evaluation of the Patient with Acute Chest Pain.
   Lee. N Engl J Med 2000 342 1187-1195.
2. Missed Diagnosis of Acute Cardiac Ischemia in the
   Emergency Department. Pope and others. N Engl J
   Med 2000 342 1163-70. Editorial N Engl J Med
   2000 342 1207-1209.
3. Is this Patient Having a Myocardial Infarction?
   Panju and others. JAMA 19982801256-63.
4. Prediction of the need for intensive care
   inpatients who came to Emergency Departments with
   acute chest pain Goldman and others. N Engl J Med
   1996 3341498-1504.
5. ST-segment Elevation in Conditions other than
   Acute Myocardial Infarction. Wang and others. N
   Engl J Med 2003 3492128-2135.
6. Triage of patients with Acute Chest Pain and
   Possible Cardiac Ischemia The Elusive Search for
   Diagnostic Perfection. Goldman and others. Ann
   Int Med 2003 139 987-995.
7. Comprehensive strategy for the evaluation and
   triage of the chest pain patient. Tatum. Ann
   Emerg Med 199729116-125.
8. A computer protocol to predict myocardial
   infarction in emergency department patients with
   chest pain. N Engl J Med 1988 318797-803.
9. Prognostic Importance of the Physical Examination
   for heart failure in non ST elevation Acute
   Coronary Syndromes The Enduring value of Killilp
   Classification. JAMA 2003 290 2174.
10. Use of the Acute Cardian Ischemia Time
    Insensitive Predictive Instrument (ACI-TIPT) to
    assist with Triage of Patients with Chest Pain.
    Selker. Ann Int Med 1998 129845-855.
11. Impact of a Clinical Decision Role on Hospital
    Triage of Patients with suspected Cardiac
    Ischemia in the Emergency Department. Reilly and
    others. JAMA 2002 288342-350.